• Archives of Plastic Surgery
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• v.48 no.6
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• pp.607-613
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• 2021

Background Breast reconstruction using an extended latissimus dorsi (eLD) flap can supplement more volume than reconstruction using various local flaps after partial mastectomy, and it is a valuable surgical method since the reconstruction area is not limited. However, when performing reconstruction, the surgeon should consider latissimus dorsi (LD) volume reduction due to postoperative chemotherapy (POCTx) and postoperative radiotherapy (PORTx). To evaluate the effect of POCTx and PORTx on LD volume reduction, the effects of each therapy-both separately and jointly-need to be demonstrated. The present study quantified LD volume reduction in patients who underwent POCTx and PORTx after receiving breast-conserving surgery (BCS) with an eLD flap. Methods This study included 48 patients who received immediate breast reconstruction using an eLD flap from January 2013 to March 2017, had chest computed tomography (CT) 7-10 days after surgery and 10-14 months after radiotherapy completion, and were observed for more than 3 years postoperatively. One surgeon performed the breast reconstruction procedures, and measurements of breast volume were obtained from axial CT views, using a picture archiving and communication system. A P-value <0.05 was the threshold for statistical significance. Results The average volume reduction of LD at 10-14 months after completing POCTx and PORTx was 64.5% (range, 42.8%-81.4%) in comparison to the volume measured 7-10 days after surgery. This change was statistically significant (P<0.05). Conclusions Based on the findings of this study, when harvesting an eLD flap, surgeons should anticipate an average LD volume reduction of 64.5% if chemotherapy and radiotherapy are scheduled after BCS with an eLD flap.

• Archives of Plastic Surgery
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• v.36 no.5
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• pp.605-610
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• 2009

Purpose: Substantial tissue necrosis after snake bites requiring coverage with flap surgery is extremely rare. In this article, we report 7 cases of soft tissue defects in the upper and the lower extremities caused by snake bites, which needed to be covered with flaps. Among the vast mass of publications on snake bites there has been no report that focuses on flap coverage of soft tissue defects due to snake bite sequelae. Methods: Seven cases of soft tissue defects with tendon, ligament, or bone exposure after snake bites were included. All patients were males without comorbidities, the average age was 35 years. All of them required coverage with a flap. In 6 cases, the defect was localized on the upper extremity, in one case the lesion was on the lower extremity. Local flaps were used in 6 cases, one case was covered with a free flap. The surgical procedures included one kite flap, one cross finger flap and digital nerve reconstruction with a sural nerve graft, one reverse proximal phalanx island flap, one groin flap, one adipofascial flap, one neurovascular island flap, and one anterolateral thigh free flap. The average interval from injury to flap surgery was 23.7 days. Results: All flaps survived without complication. All patients regained a good range of motion in the affected extremity. Donor site morbidities were not observed. The case with digital nerve reconstruction recovered a static two point discrimination of 7 mm. The patient with foot reconstruction can wear normal shoes without a debulking procedure. Conclusion: The majority of soft tissue affection after snake bites can be treated conservatively. Some severe cases, however, may require the coverage with flap surgery after radical debridement, especially, if there is exposure of tendon, bone or neurovascular structures. There is no doubt that definite coverage should be performed as soon as possible. But we also want to point out that this principle must not lead to a premature coverage. If the surgeon is not certain that the wound is free of necrotic tissue or remnants of venom, it is better to take enough time to get a proper wound before flap surgery in order to obtain a good functional and cosmetic result.

• Archives of Plastic Surgery
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• v.45 no.3
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• pp.229-238
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• 2018

Background Nipple-sparing mastectomies (NSMs) are increasingly performed to obtain the best aesthetic and psychological outcomes in breast cancer treatment. However, merely preserving the nipple-areolar complex (NAC) does not guarantee a good outcome. Darkly pigmented NACs and a tendency for poor scarring outcomes are particular challenges when treating Asian patients. Herein, we review the reconstructive outcomes following NSM at Singapore General Hospital. Methods All breasts reconstructed following NSM over an 11-year period from 2005 to 2015 were reviewed. Information was collected from the patients' records on mastectomy indications, operative details, and complications. Patient satisfaction, breast sensation, and aesthetic outcomes were evaluated in 15 patients. Sensation was quantified using the Semmes-Weinstein monofilament test. Results A total of 142 NSMs were performed in 133 patients for breast cancer (n=122, 85.9%) or risk reduction (n=20, 14.1%). Of the procedures, 114 (80.2%) were autologous reconstructions, while 27 (19.0%) were reconstructions with implants. Complications occurred in 28 breasts (19.7%), with the most common complication being NAC necrosis, which occurred in 17 breasts (12.0%). Four breasts (2.8%) had total NAC necrosis. The overall mean patient satisfaction score was 3.0 (good). The sensation scores were significantly diminished in the skin envelope, areola, and nipple of breasts that had undergone NSM compared to non-operated breasts (P<0.05). Half of the subset of 15 patients in whom aesthetic outcomes were evaluated had reduced nipple projection. Conclusions Immediate reconstruction after NSM was performed with a low complication rate in this series, predominantly through autologous reconstruction. Patients should be informed of potential drawbacks, including NAC necrosis, reduced nipple projection, and diminished sensation.

• Archives of Plastic Surgery
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• v.40 no.2
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• pp.97-103
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• 2013

Background Velopharyngeal insufficiency (VPI) may persist after primary repair of the cleft palate, and surgical correction is necessary in many cases. The purpose of this study is to evaluate the effect of double opposing Z-plasty (DOZ) in cleft palate patients suffering from VPI after primary two-flap palatoplasty. Methods Between March 1999 and August 2005, we identified 82 patients who underwent two-flap palatoplasty for cleft palate repair. After excluding the patients with congenital syndrome and mental retardation, 13 patients were included in the final study group. The average age of the patients who underwent DOZ at was 5 years and 1 month. Resonance, nasal emission, and articulation were evaluated by a speech pathologist. The velopharyngeal gaps were measured before and after surgery. Results Six patients attained normal speech capabilities after DOZ. The hypernasality grade was significantly improved after surgery in all of the patients (P=0.0015). Whereas nasal emission disappeared in 8 patients (61.5%), it was diminished but still persisted in the remaining 5 patients. Articulation was improved in all of the cases. In two cases, the velopharyngeal gap was measured using a ruler. The gap decreased from 11.5 to 7 mm in one case, and from 12.5 to 8 mm in the second case. Conclusions The use of DOZ as a surgical option to correct VPI has many advantages compared with other procedures. These include short surgery time, few troublesome complications, and no harmful effects on the dynamic physiological functioning of the pharynx. This study shows that DOZ can be another option for surgical treatment of patients with VPI after two-flap palatoplasty.

• Archives of Plastic Surgery
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• v.49 no.4
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• pp.531-537
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• 2022

Wide-awake, local anesthesia, no tourniquet (WALANT) is a technique that removes the requirement for operations to be performed with a tourniquet, general/regional anesthesia, sedation or an anesthetist. We reviewed the WALANT literature with respect to the diverse indications and impact of WALANT to discuss the importance of future surgical curriculum integration. With appropriate patient selection, WALANT may be used effectively in upper and lower limb surgery; it is also a useful option for patients who are unsuitable for general/regional anesthesia. There is a growing body of evidence supporting the use of WALANT in more complex operations in both upper and lower limb surgery. WALANT is a safe, effective, and simple technique associated with equivalent or superior patient pain scores among other numerous clinical and cost benefits. Cost benefits derive from reduced requirements for theater/anesthetic personnel, space, equipment, time, and inpatient stay. The lack of a requirement for general anesthesia reduces aerosol generating procedures, for example, intubation/high-flow oxygen, hence patients and staff also benefit from the reduced potential for infection transmission. WALANT provides a relatively, but not entirely, bloodless surgical field. Training requirements include the surgical indications, volume calculations, infiltration technique, appropriate perioperative patient/team member communication, and specifics of each operation that need to be considered, for example, checking of active tendon glide versus venting of flexor tendon pulleys. WALANT offers significant clinical, economic, and operative safety advantages when compared with general/regional anesthesia. Key challenges include careful patient selection and the comprehensive training of future surgeons to perform the technique safely.

• Archives of Craniofacial Surgery
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• v.25 no.4
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• pp.161-170
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• 2024

Background: The eyes are the central aesthetic unit of the face. Maxillofacial trauma can alter facial proportions and affect visual function with varying degrees of severity. Conventional approaches to reconstruction have numerous limitations, making the process challenging. The primary objective of this study was to evaluate the application of three-dimensional (3D) navigation in complex unilateral orbital reconstruction. Methods: A prospective cohort study was conducted over 19 months (January 2020 to July 2021), with consecutive enrollment of 12 patients who met the inclusion criteria. Each patient was followed for a minimum period of 6 months. The principal investigator carried out a comparative analysis of several factors, including fracture morphology, orbital volume, globe projection, diplopia, facial morphic changes, lid retraction, and infraorbital nerve hypoesthesia. Results: Nine patients had impure orbital fractures, while the remainder had pure fractures. The median orbital volume on the normal side (30.12 cm³; interquartile range [IQR], 28.45-30.64) was comparable to that of the reconstructed orbit (29.67 cm³; IQR, 27.92-31.52). Diplopia improved significantly (T(10)= 2.667, p= 0.02), although there was no statistically significant improvement in globe projection. Gross symmetry of facial landmarks was achieved, with comparable facial width-to-height ratio and palpebral fissure lengths. Two patients reported infraorbital hypoesthesia at presentation, which persisted at the 6-month follow-up. Additionally, five patients developed lower lid retraction (1-2 mm), and one experienced implant impingement at the infraorbital border. Conclusion: Our study provides level II evidence supporting the use of 3D navigation to improve surgical outcomes in complex orbital reconstruction.

• Maxillofacial Plastic and Reconstructive Surgery
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• v.11 no.1
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• pp.297-308
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• 1989

These are two case reports of recurrent ossifying and cemento-ossifying fibroma in a year or 5 months following conservative treatment. Ossifying fibroma or cemento-ossifying is a relatively uncommon benign fibro-osseous tumor of the jaws, and is generally believed to originate from periodontal ligaments. In recent, it is not demanded more differentiation of ossifying, cementifying and cemento-ossifying fibroma due to the thought that these lesions represent a spectrum of the same disease process rather than separate entities. The tumor commonly presents as an asymptomatic mass lesion and is usually well-circumscribed clinically so that conservative surgical excision has been the treatment of choice, but on occasion extended surgical procedures may become necessary, especially for those tumors which demonstrate rapid expansions and are poorly encapsulated (either initially or when recurrent) and when tumor growth is progressed aggressively or recurrent. En-bloc resection of mandible with iliac bone and inferior alveolar nerve graft was performed in case 1, recurrent cemento-ossifying fibroma of 32-year old male patient, and extended surgical enucleation of mass including normal marginal bone was done in case 2, recurrent ossifying fibroma of 72-year old female patient. By follow-up check of the patients, we obtained good result without any sings of recurrence.

• Maxillofacial Plastic and Reconstructive Surgery
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• v.33 no.2
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• pp.158-165
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• 2011

A 73-year-old Korean female patient with a fully edentulous mandible was planned to have five implant fixtures installed in the anterior mandible for the fixed prosthesis. After 3-dimensional (3D) computed tomographic scanning was transferred to OnDemand3D$^{(R)}$ (Cybermed Co., Seoul, Korea) software program for the virtual planning, five fixtures of MK III Groovy RP implants of Branemark System$^{(R)}$ (Nobel Biocare AB Co., Goteborg, Sweden) were installed in the anterior mandible between both mental foramens using In2Guide$^{(R)}$ (CyberMed Co., Seoul, Korea) mucosa-supported surgical template with Quick Guide Kit$^{(R)}$ (Osstem Implant Co., Seoul, Korea) systems. Fixture installations were completed successfully without any complications, such as mental nerve injury, bony bleedings, fenestrations and other unexpected events. Postoperative computed tomographic scans were aligned and fused to the planned implant, then angular and linear deviations were compared with the planned virtual implants. The mean angular deviation between the planned and actual implant axes was $3.42{\pm}1.336^{\circ}$. The mean distance between the planned and actual implant at the neck area was $0.544{\pm}0.290$ mm horizontally and $0.118{\pm}0.079$ mm vertically. The average distance between the planned and actual implant at the apex area was $1.166{\pm}0.566$ mm horizontally and $0.14{\pm}0.091$ mm vertically. These results could be considered more precise and accurate than previous reports, and even our recent results. The entire procedures of this case are reported and reviewed.

• Archives of Plastic Surgery
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• v.47 no.5
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• pp.428-434
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• 2020

Background Three-dimensional (3D) model printing improves visualization of anatomical structures in space compared to two-dimensional (2D) data and creates an exact model of the surgical site that can be used for reference during surgery. There is limited evidence on the effects of using 3D models in microsurgical reconstruction on improving clinical outcomes. Methods A retrospective review of patients undergoing reconstructive breast microsurgery procedures from 2017 to 2019 who received computed tomography angiography (CTA) scans only or with 3D models for preoperative surgical planning were performed. Preoperative decision-making to undergo a deep inferior epigastric perforator (DIEP) versus muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flap, as well as whether the decision changed during flap harvest and postoperative complications were tracked based on the preoperative imaging used. In addition, we describe three example cases showing direct application of 3D mold as an accurate model to guide intraoperative dissection in complex microsurgical reconstruction. Results Fifty-eight abdominal-based breast free-flaps performed using conventional CTA were compared with a matched cohort of 58 breast free-flaps performed with 3D model print. There was no flap loss in either group. There was a significant reduction in flap harvest time with use of 3D model (CTA vs. 3D, 117.7±14.2 minutes vs. 109.8±11.6 minutes; P=0.001). In addition, there was no change in preoperative decision on type of flap harvested in all cases in 3D print group (0%), compared with 24.1% change in conventional CTA group. Conclusions Use of 3D print model improves accuracy of preoperative planning and reduces flap harvest time with similar postoperative complications in complex microsurgical reconstruction.

• Korean Journal of Bronchoesophagology
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• v.13 no.2
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• pp.50-56
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• 2007

Background and Objectives: Laryngotracheal stenosis and its reconstruction in children is a highly challenging field to airway surgeons, and the way of stenting after a reconstructive surgery is still controversial. The aims of this study were to analyze the single institutional experiences of laryngotracheal reconstruction (LTR) in the pediatric patients with laryngotracheal stenosis and to compare the outcomes of single-stage LTR (SSLTR) with conventional two-stage LTR (TSLTR) in these patients. Materials and Methods: Medical records of 14 children (mean age 4.1 years) were reviewed, who received 20 LTR including 6 revisions for their moderate to severe subglottic stenosis and/or combined posterior glottic stenosis. Of these 20 LTR, tracheostoma was temporarily maintained after LTR in 12 cases (TSLTR) or not in the other 8 cases (SSLTR). Results: Overall decannulation rate of LTR that were performed before and after the year of 2003 was 40% (4/10) and 70% (7/10) respectively. Decannulation rate was 42% (5/12) in TSLTR group and 75% (6/8) in SSLTR group (P = 0.197). Mean interval to decannulation after LTR was 9.8 months and 7.2 days in TSLTR and SSLTR groups respectively (P = 0.004). A number of additional touch-up procedures that were required after LTR was 4 in TSLTR and 2.7 in SSLTR group (P = 0.238). Major complication rate was similar in both groups (33% in TSLTR and 38% in SSLTR, P = 0.910). Conclusion: A laryngotracheal reconstruction in children is a technically demanding procedure and its outcome is largely dependent on the surgeon's experience. Albeit there was a tendency that SSLTR ofters a higher decannulation rate, less additional touch-up procedures and similar complication rates, a shorter interval to decannulation after LTR was the only advantage that was confirmed as statistically significant in this study.